This document discusses improving patient safety and care coordination. It notes that 33% of Medicare patients were harmed during skilled nursing facility stays, and 59% of incidents were preventable. Poor care coordination can increase costs by $25-45 billion annually. The document advocates for standardizing care practices and improving collaboration and communication among care teams to reduce medical errors and associated costs. It argues that effective care coordination requires engaging all players, including doctors, nurses and pharmacists, with the patient at the center.

1. EXECUTIVE SUMMARY
Empowering clinicians to provide
safer, more consistent care
of MEDICARE PATIENTS were harmed in
some way during skilled nursing facility stay33%
59%
$2.8billion
of incidents were
clearly or likely
PREVENTABLE1
Failures in care coordination
can increase costs by
How standardization and collaboration across care teams
can lead to better outcomes and reduced costs
spent on hospital treatment for harm
caused in skilled nursing facilities
1
~20%
of patients experienced adverse events 3
weeks post-discharge from hospitals, nearly
3/4 of which could have been prevented
2
$25 - 45billion annually
3
3
Peer-reviewed research indicates that a proactive
approach to patient safety could prove more beneficial
& effective than the reactive approach common today.
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2. 400,000+
more than previously
estimated4
Poor coordination of
patient care ranked
among TOP TEN safety
concerns for hospitals
5
GETTING STARTED
deaths are caused
by preventable
medical errors
Two IOM reports emphasized patient
safety over a decade ago, but medical
errors still persist as the
KILLER IN
THE U.S.4
CARE COORDINATION: NOW’S THE TIME
Failures in care delivery can lead to
PATIENT INJURIES DECLINING CLINICAL OUTCOMES HIGHER COSTS3
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3. amounting to an estimated
in excess medical costs7
GETTING STARTED
of patients who die in the Intensive Care Unit
may have had a missed diagnosis that contributed
to their deaths
6
8%
Hospital Acquired Infections account for
100,000deaths per year
$33 BILLION
Checklists are only followed 50% of the time7
1 in 10hospitals lack
checklists to prevent
bloodstream infections
25%
of hospitals lack checklists
to prevent pneumonia in
ventilator patients
7
The best place to start improving patient safety & care coordination
is to focus on the largest group of direct patient care providers:
A good place to start is by providing nurses:
Access to
evidence-based
content &
guidelines
A solution available
for maintaining
knowledge & skills
for all nursing staff
The availability to
train & orient
in the classroom
& at the bedside
Presented in
formats
most suited
for nurses
NURSES
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4. Patient safety must become HABITUAL and ROUTINE
Effective care coordination requires multiple players to engage in
purposeful communication with THE PATIENT AT THE CENTER
Care coordination should be a
shared responsibility among
doctors, nurses & pharmacists
One of the primary benefits
of care coordination is lower cost
TEAMING UP
Patient care is a shared responsibility and should be
APPROACHED AS A TEAM
The physician’s role in care coordination is critical.
With the emergence of electronic
healthcare records (EHRs), there’s a
greater opportunity for:
• improving information
transfer between physicians
• developing standardized
patient discharge instructions
Nurses are best positioned to bring a strong perspective
and leadership to assist individual’s health
needs across the continuum of care:
• may need additional resources
and training to improve care
coordination
• involvement in care collaboration
is considered integral to the
success of healthcare reform
The Institute of Medicine estimates that the POTENTIAL
HEALTHCARE SAVINGS from better care coordination could reach
$
240 BILLION
9
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5. IT CAN WORK
Health & Human Services data reported that relative to 2010,
in 2012 we achieved a 9% decrease in hospital acquired
conditions (adverse drug events, patient falls, infections, etc.10
).
9%
Care coordination, among patient safety strategies,
CAN HELP PROTECT PATIENTS.
1
Adverse events in skilled nursing facilities: national incidence among medicare beneficiaries. February 2014. Department of Health and Human Services; Office of Inspector General.
2
Adverse events after hospital discharge. August 2014. Agency for Healthcare Research and Quality.
3
Reducing waste in health care. Health Aff, Health Policy Brief. December 13, 2012.
4
James, John T. A new evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety. 2013; 9 (3): 122-128. doi: http://10.1097/PTS.0b013e3182948a69.
5
"Top 10 Patient Safety Concerns for Healthcare Organizations." ECRI Institute. (April 2014): 4. https://www.ecri.org/EmailResources/PSRQ/Top10/Top10PSRQ.pdf
6
Winters B., et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf 2012 Nov; 21 (11): 894-902. doi:10.1136/bmjqs-2012-000803
7
Stone P.W., etc. State of infection prevention in US hospitals enrolled in the national health and safety network. Am Jrn Inf Control February 2014 42(2):94-99
doi:10.1016/j.ajic.2013.10.003
8
Journal of Patient Safety: September 2013 - Volume 9 - Issue 3 - p 122–128 doi: 10.1097/PTS.0b013e3182948a69
9
IOM. Roundtable on value & science-driven health care: the healthcare imperative: lowering costs and improving outcomes. Workshop series summary, Washington, DC: National
Academies Press, 2010.
10
New HHS data shows major strides made in patient safety, leading to improved care and savings. May 2014. Department of Health and Human Services: Centers for Medicare
and Medicaid.
11
Reducing waste in health care. Health Aff, Health Policy Brief. December 13, 2012.
To learn how ClinicalKey can contribute to care standardization
at your organization, visit clinicalkey.com/info/collaborativecare
15k 560k $4.1B
Projected to have
prevented nearly
Reducing preventable
patient harm events by
Saving our
healthcare system
in costs11
inpatient deaths
This improvement in care coordination is:
Success will come through a combination of
two broad capabilities:
1) health IT solution that allow for the use of evidence-based
practice in clinical decision support by all providers
across the continuum of care
2) a change in our care delivery culture
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